Please note that the copyright for this course project is retained by the instructor.

This Problem Based Learning Case is presented to first and second year medical
students at the University of Nebraska College of Medicine. The students work
through an actual case presentation of an environmental health problem. The instructor
guides the discussion as the students work through the case. In an interactive
question/discussion format, needed information is provided to the students to
work through the differential diagnosis and arrive at the appropriate conclusion.
This case focuses on occupational pneumonitis and carpal tunnel syndrome.

1. Review basic interviewing skills from M1 year. (Aug 29)
2. Take an occupational and exposure history. (Aug 29)
3. Conduct a target or focused physical examination appropriate to the patient's presenting concerns. (Aug 29)
4. Discuss the importance of the occupational and exposure history as it relates to disease etiology and to considerations about the impact of the illness on the patient's occupation. (Aug 29 & Sep 12)
5. Inform a patient of the diagnosis and therapy and provide appropriate patient education. (Sep 12)
6. Identify challenges in providing effective patient education. (Sep 12)
7. Discuss the implications of a serious chronic illness on an individual's sense of self esteem and discuss how a rural person's reaction might be different from that of someone from an urban area. (Aug 29 & Sep 12)

LuAnn/Randy Johnson is 47 years old; s/he comes from Cuming County to visit your office in West Point, Nebraska. S/he has been experiencing coughing at-tacks for the past several months.

Vital signs: T = 37.3° C, P = 96, R = 30 at rest, and BP = 164/92.

The patient appears to be in mild respiratory distress as s/he walks down the hall to your office.. Contractions of the stemocleidomastoid muscles are visible as you take the history.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

What is the differential diagnosis of chronic cough?
What other questions should you ask?

The information below will be obtained by students during an interview/physical exam of the standardized patient; a copy of these pages will be given to all students at the end of today's session.

History Of Present Illness

S/he has been experiencing these coughing attacks frequently during the day. Sometimes s/he is also short of breath with exertion when s/he does her/his work on the farm. Lately s/he has been coughing at night. The cough was especially bad last night and s/he does not feel well today.

Mr/s. Johnson states that s/he first noticed the cough when competing in track in high school. S/he has always had trouble with colds "going into my chest." S/he smoked for a year or so while in college but gave it up because it aggravated the cough.

Current problems started with a cold in late spring. For a time the sputum s/he coughed up was yellow, but now it is white. S/he also complains of a stuffy nose and occasional headaches. The pain is above the eyebrows and behind the eyes. All of the symptoms are worse after s/he spends 6 or 8 hours in the swine confinement building, which s/he does almost every day.

S/he has tried some Primatene tablets s/he purchased at the grocery store. They help somewhat but s/he is concerned that they may not be good for her/him. S/he has been seeing another doctor who has given her/him a couple of round of an-tibiotics, but s/he doesn't seem to be getting any better.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

What does nocturnal cough suggest? Why is nocturnal cough not well tolerated by patients?
What was most likely the cause of the symptoms in high school?
How could the recent viral infection have contributed to the problem?
What is Primatene and what is its mechanism of action?
How could the work as a hog farmer affect the problem?
What additional questions should you ask about her/his work environment?

Additional History

Other medical problems include a history of hypertension and mild elevations in blood glucose noted when s/he goes to the doctor for annual physical examina-tions. S/he has a family history of seasonal allergies (a son) and asthma (an uncle).

Randy and LuAnn Johnson have four children, 3 sons and a daughter. The children are in their twenties. All three sons have gone to college and returned to live on the farm to help their parents. Two of the sons are married. The sons are in good health. Their daughter lives in an apartment in town; she had viral encephalitis as a child and is now mentally handicapped. She is supervised by members of the county mental retardation office who check up on her periodically.

They own a 1500 acre farm together with her/his brothers and her/his main job is to run the swine confinement unit. S/he states that it has been stressful at times, working with their sons. "They got these new fangled ideas from college, and they're always wanting to try something new."

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

Is the family history of atopy (seasonal allergies) and asthma of relevance?
For what other occupational health problems is s/he at risk through her/his work in swine confinement buildings?
What kind of respiratory protection should s/he wear? What else can s/he do to decrease any work-related respiratory symptoms?
What do you expect to find on physical examination?

Focused Physical Examination

Other than the patient's appearance of dyspnea, the exam (HEENT, neck, lungs, heart, and abdomen) is unremarkable except for auscultation of the lungs, which reveals diffuse wheezing. SEE EXHIBIT A.

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Students are to actually examine the patients; the students have been in-structed to bring appropriate equipment For the lung and heart exams, they are to examine the patients over their clothing, demonstrating proper technique; be sure that students realize that this is not acceptable practice in the real world Tell students the findings as they do each part of the exam. For this patient's complaint, a focused examination should include head, eyes, ears, nose, throat, neck, chest, lungs, heart, and abdomen. Students should explain why they are doing these exams; "to be complete" is not good enough. The HEENT exam will reveal signs of infection, such as, sinusitis, or seasonal allergies; an abdominal problem can cause cough by irritating the diaphragm. After the demonstrate proper technique for auscultation of the lungs, play the audio Ape, EXHIBIT A.

Discuss the mechanisms for the abnormal physical findings.
What other tests would be valuable at this time?

Chest X-Ray

See EXHIBIT B. One film is an old film from several years ago that was read as normal; the other film is today's film.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

Interpret the x-ray. Explain the difference in the two films.

The current films shows hyperexpansion as compared to the old film, which is normal.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

Explain the mechanism of the hyperexpansion in the patient's condition.

(End of Student Handout)

Wrap-Up

1. Hand out summary of this session.
2. Have a student summarize the case.
3. Review and prioritize learning issues; discuss possible resources.
4. Since each student will be in a different group for the next two PBL sessions for this case, each one should copy the learning issues and share them with the PBL group members.

1. Summarize/review case.
2. Review and discuss learning issues.
Instead of asking for volunteers to discuss learning issues, randomly ask differ-ent students to address the learning issues. This insures that everyone is pre-pared to discuss an major learning issues and not one issue for which they es-pecially prepared. NOTE: students will have come from different ICEgroups and may have different learning issues.
3. List and critique resources used. During session 2 or 3, each student should turn in a relevant journal article. Please review the articles, make comments, and return them to students. You may also ask students to summarize the articles.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.

Laboratory Data

Your office is attached to the hospital; you send the patient over to measure the oxygen saturation with an oximeter; the value is 91%. Then you do arterial blood gases, and the values are as follows: pH = 7.50, pC02 = 30, pO2 = 62.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

Interpret the blood gases.
Does the patient need supplemental oxygen? Why is the pC02 decreased?

Give copy of summary page to all students for this part.

PULMONARY FUNCTION TEST*

BEFORE BD

AFTER: ALUPENT

MECHANICS

PRED

MEAS

%PRED

MEAS

%PRED

FVC(L)

5.024

4.261

85

4.665

93

FEV1 (L)

4.032

2.409

60

2.799

69

FEV3 (L)

4.737

3.384

71

3.83

81

FR1iNC%

80

56

70

60

75

FEV3/FVC%

94

79

84

82

87

FEF25-75% (US)

3.978

1.014

25

1.261

32

FEFMAX (US)

9.19

7.402

81

7.9

86

FEF25% (US)

8.127

3.461

43

4.192

52

FEF50% (US)

5.521

1.153

21

1.499

27

FEF75% (US)

2.548

0.346

14

0.423

17

FIVC (L)

5.024

4.038

80

4.178

83

FIV1 (L)

4.873

4.011

82

4.178

86

FIV11FIVC%

97

99

102

100

103

FIFMAX (US)

5.2

5.923

114

6.846

132

MW (UMIN)

158

105

66

116

73

LUNG VOLUMES

PRED

MEAS

%PRED

VC(SLOW)(L)

5.024

4.428

88

IC (L)

3.467

3.899

111

ERV (L)

1.557

0.529

34

RV (L)

1.978

3.414

173

TLC(HE) (L)

6.968

7.842

113

RV/TLC%

28

43

154

FRC(HE) (L)

3.535

3.943

112

TGV(BOX) (L)

3.535

5.27

149

TRAPPED GAS (L)

0

1.327

RESlSTANCE

PRED

MEAS

%PRED

RAW (CMH20/US)

1.5

2.5

167

GAW (1/CMH20/US)

0.667

0.4

60

DIFFUSION

PRED

MEAS

%PRED

DSB (ML STPD/MiN/MM HG)

36.8

39.29

107

DSBNA

5.38

7.13

133

*note these are values for a male patient

STOP-
DISCUSS THIS SECTION BEFORE YOU CONTINUE

How is the spirogram performed? What do these test results mean? On what l are the predicted values based?
What are the airway changes associated with this problem?
What pulmonary function test could the patient do at home to monitor the condi-tion?
How might the patient's work contribute to the problem? Could it have caused this condition?
What might you see if you were to perform bronchoscopy with bronchoalveolar lavage and a bronchial wall biopsy? What cell types will likely be present in increased numbers?
What mediators of inflammation are elevated in this condition? What is happening at the cellular level in this condition?
What medications can be used to control the inflammation in this condition and what are their mechanisms of action?
What patient teaching needs to be done?

Wrap-Up

1. Hand out summary of this session.
2. Have a student summarize the case.
3. Review and prioritize learning issues; discuss possible resources.

1. Summarize/review case.
2. Review and discuss learning issues. Instead of asking for volunteers to discuss learning issues, randomly ask differ-ent students to address the learning issues. This insures that everyone is prepared to discuss all major learning issues and not one issue for which they es-pecially prepared.
3. List and critique resources used. During session 2 or 3, each student should turn in a relevant journal article. Please review the articles, make comments, and return them to students. You may also ask students to summarize the articles.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.

Now that s/he can breathe, s/he starts to tell you about another problem, her/his right hand has been going to sleep and hurting.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What are the possible causes of the new problem? Occupational causes should be considered as well as primary diseases.

Additional History

The numbness and pain in the right hand comes and goes; it seems to be worse at night and while driving. S/he is not sure whether all the fingers are involved or just some of them. It usually helps if s/he shakes her hands. There is a sharp pain in the right arm and shoulder at times, also. S/he is right handed.

The work history is remarkable for having worked in the Iowa Beef Packers plant in West Point as a meat cutter for 3 summers while in college. S/he also worked there for a couple of years while s/he was getting started in farming. S/he suffered from pain in the right wrist at that time. This still recurs occasionally when s/he spends a lot of time at the computer entering and analyzing data concerning the swine operation. There is no history of fracture to the area.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What physical exam/tests are indicated at this time for the new problem?

Focused Physical Exam

Exam of the cervical spine reveals no tenderness and no limited range of mo-tion. Peripheral pulses are good. Motor strength in both upper extremities including the hands is normal and equal bilaterally. There is no apparent muscle atrophy or fasciculations. Sensation is intact in both upper extremities. Having the patient flex both wrists results in tingling in right thumb, index, and long fingers after about 30 seconds. Tapping the palmar aspect of the wrists with a reflex hammer causes a sharp pain to go down into the same fl needs on the right.

STOP
DISCUSS THIS SECTION BEFORE YOU CONTINUE

What are the names of the two tests described at the end of this section?
What is the most likely cause of her/his wrist pain? What structures are af-fected? How can this problem be treated? How can it be prevented?

Diagnoses, Therapy, And Patient Education

The standardized patient will return during the next ICE session. After discuss-ing learning issues, you will inform the patient of her/his diagnoses, explain the under-lying mechanisms for her/his conditions, and inform of therapy/prevention for the conditions, including writing prescription for any pharmacological therapy (one for the breathing problem and one for the right hand pain). Use EXHIBIT C to write your prescriptions.

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Wrap-Up

1. Hand out summary of this session.
2 Have a student summarize the case.
3 Review and prioritize learning issues; discuss possible resources

1. Summarize/review case.
2. Review and discuss learning issues. Instead of asking for volunteers to discuss learning issues, randomly ask differ-ent students to address the learning issues. This insures that everyone is pre-pared to discuss an major learning issues and not one issue for which they es-pecially prepared. Since students are coming from different PBL groups, they may have different learning issues; it may take a few minutes to consolidate the various learning issues.
3. List and critique resources used.
4. Update hypotheses (add, delete, and rank) and inquiry/management decisions.

Give copy of the following information to all students.

Diagnoses, Therapy, And Patient Education

Students will inform the patient of her/his diagnoses, explain the underlying mechanisms for her/his conditions, inform of therapy/prevention for the conditions, including writing prescriptions for any pharmacological therapy (one for asthma and one for the carpal tunnel syndrome), and in general provide patient education.

EXHIBIT D is a sample of Atrovent that can be used to instruct the patient on how to use an inhaler. NOTE: this is not the drug of first choice for this patient; however, for demonstration purposes, the technique is identical to other inhalers. EXHIBIT E is a sample patient education pamphlet for carpal tunnel syndrome that can be given to the patient.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

Review the prescriptions that students were assigned to write at the end of last session.
The group should come to a consensus about how to approach the patient and what to tell him/her.

(End student handout)

The information on the following page is a summary of what should have been done with this patient; copies of this page will be given to all students at the end of today's session

Diagnoses, Therapy, And Patient Education

The patient is informed of her/his diagnoses: asthma and carpal tunnel syn-drome. In addition, the physiological mechanisms/causes for each are explained. Prescriptions are given for a beta agonist bronchodilator (e.g., albuterol inhaler, 2 in-halations every 4 hours as needed) and an inhaled anti-inflammatory agent (e.g., flunisolide, 2 inhalations twice daily morning and evening). S/he is instructed in the proper use of a nebulizer; the patient demonstrated the use of the nebulizer to the clinician. S/he is also informed of environmental triggers that can exacerbate the asthma. The patient is not willing to change her/his occupation. An air flow mask respirator is discussed. Also, a peak expiratory flow rate (PEFR) meter and home hand-bulb nebulizer with albuterol solution and normal saline are prescribed for the patient, and s/he is instructed in their use.

In regards to the carpal tunnel syndrome, nerve conduction studies were not performed to confirm the diagnosis at this time. Conservative therapy was encour-aged (rest, splints, remove precipitating factors, and non steroidal anti inflammatory agents (e.g., ibuprofen, 600 mg., 1 PO TID with food). Because the most likely pre-cipitating factor is repetitive motion trauma from using the computer, a wrist support was advised. If the condition continues or worsens, other options are a local injection of steroid into the affected area and surgery. Most cases will resolve without surgery, however. Nerve conduction studies should be done prior to surgery to confirm the diagnosis. Other causes should be ruled out, such as hypothyroidism.

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DISCUSS THIS SECTION BEFORE YOU CONTINUE

Turn in list of patient education issues and problems encountered during the patient interview to Mary Ann Manners in the self addressed envelope that isprovided.

Summary And Integration Of Learning

1. Hand out summary of this session.
2. Review objectives for this case.
3. What did we team?
4. Could we have gone through the case more efficiently?

If Indicated, Review Group Process

1. Did everyone get a chance to participate?
2. Did someone dominate the discussion?
3. Did someone not contribute or participate as fully as they could have?
4. What actions contributed to effective group process?
5. How can we do a better job next time?

PBL Written Evaluation

STOP
END OF CASE

This document was last modified on 06/14/2000 03:07:54 PM

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